Neurology ECHO Network Waitlist Form

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* 1. First name

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* 2. Last name

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* 3. Email address

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* 4. Mobile number

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* 5. What is your profession?

GP Specialist

Non- GP Specialist (please also select other and specify)

Nurse

IMG

Junior Doctor

Pharmacist

Allied Health Professional (please also select other and specify)

Other (please specify)

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* 6. Workplace name

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* 7. Workplace suburb

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* 8. Is your work location classified as:

Metropolitan SA

Regional SA

Remote SA

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* 9. Would your work environment be described as

Solo practice

Team of practitioners from the same clinical discipline

Team of practitioners of different clinical disciplines

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* 10. Do you have a patient case you would like to discuss at the network?

Yes

Unsure

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* 11. What would you like to gain from joining the Neurology ECHO Network?

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* 12. For each of the curriculum topics listed below, please share your learning needs and requests for specific focus areas:

Movement disorders including Parkinson's disease, dystonia, essential tremor

Peripheral neuropathy

Headaches & Migraines

Seizures and epilepsy

Neurological symptoms and when to refer

Stroke/TIA

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* 13. How did you hear about the Neurology ECHO Network?

SAPMEA

Adelaide PHN

Country SA PHN

SA Health / Wellbeing SA

GP Integration Unit

Direct email invitation

Social media

Word of mouth

Other (please specify)

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* 14. If you are a RACGP member and would like to claim 40 points for participating in this Peer Group Learning Accredited Activity (Reviewing Performance Category 1), please provide us with your RACGP membership number.

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* 15. If you are an ACRRM member and would like to claim points for participating in this Case Discussion Activity (Performance Review Category), please provide us with your ACRRM membership number.

Thank you for completing this waitlist form. We will be in touch if a place becomes available.
In meantime you can find resources and the recordings for each session's didactic presentation on our webpage: https://sapmea.asn.au/echo/neuro

Project ECHO aims to build your professional networks and support. By joining the Neurology ECHO Network, your name, profession, workplace and email will be shared with other participants. If you do not want your details to be shared with other members, please email us at echo@sapmea.asn.au